Diagnosis at the Pool Hall

Joseph and I were introduced by our mutual friend Tom at a Texas pub. My husband and I had cycled through the July heat to meet the two of them that Saturday afternoon, arriving a little early. Hustling inside to the A/C, we ordered beers and racked the pool balls for a game. We were well into both by the time Joseph and Tom arrived.

Joseph was a trim, middle-aged white man whose hair, eyebrows and soul patch were fairer than his skin, giving him a crisp and youthful look. He was a stone carver by trade, and he wore work boots and a plaid shirt. And he lurched. It was dark in the pub, but his seesaw gait was hard to miss.

As Tom introduced everyone, Joseph said something offhand about his feet hurting, then he changed the subject. We hit it off fast — Joseph was friendly and had a dry wit. But his movements were off. Even though he was sober, he had trouble grasping his drink, and he had to hold on to Tom whenever he moved from his stool to the pool table or bar. He wisecracked about it, but something was wrong.

I ventured a few questions.

The problem started two days before, when Joseph noticed his feet were tingling. Thinking his pneumatic tools might be affecting his circulation, he loosened his boots. But his hands, too, felt tingly and numb. The next day his legs felt rubbery, and he began to stagger. “I was losing my sense of contact with the ground,” he told me.

At the time, Joseph was working on an 11-by-6½-foot panel of Texas limestone featuring two rearing lions. (It would grace the entrance to the client’s Ferrari garage, which he would showcase to guests during Austin’s Formula One races that fall.) The weakness in his legs made it difficult to carve. “When I got down on my knees to work, I had a little bit of trouble standing up,” he said. “I had to climb up the lions with my arms.” As he made his way around the sculpture studio by holding on to worktables and stone blocks for support, his fellow carvers thought he was joking.

Barroom Diagnosis

I set down my beer and asked my new friend if he minded an exam “for entertainment purposes only.” (I’m not licensed to practice in Texas, much less in a Texas bar.)

Joseph looked well enough. He wasn’t sweating or short of breath. The pulse in his thick wrist was normal. I asked him to squeeze my hand. His grip was firm — but not forceful. A guy who works with six-ton chunks of rock should have melded my fingers together. “That’s all you got, stone carver?” I asked.

To assess his coordination, I asked him to touch his finger to his nose and back to my finger. He did fine.

I picked up the cue ball and asked Joseph to dangle his legs off the bar stool. Then I tapped beneath his knees. His leg wouldn’t kick. My husband and I whacked our own knees, verifying that a pool ball can indeed elicit such reflexes. For us, it did.

Could Joseph be having a stroke? I rummaged through my bag for a bicycle light and shined it on his pupils, then examined his face and head. Encouragingly, he had no droopy eyelids, no facial numbness, no trouble lifting his pale eyebrows or following my finger. And anyway, strokes typically affect only one side of the body.

I asked more questions. No vomiting, diarrhea, trouble breathing, headache, vision problems, fever, confusion or other major complaints. In fact, apart from chronic shoulder pain, Joseph’s only medical history was an underactive thyroid gland and two decades as an intermittent smoker; he had quit a year before. His balance troubles probably weren’t originating in his brain, or from his beer.

If it wasn’t a stroke, what else could it be? Poisoning from heavy metals or neurotoxic fish was a possibility, since they can cause numbness and weakness in the limbs, too. But he felt too well for that. A pinched nerve creates problems in one specific area of the limb, whereas Joseph’s numbness involved both feet and hands in their entirety. This “stocking and glove” pattern of symptoms is what you see with nerve damage from long-standing diabetes, but diabetes damage wouldn’t start this abruptly or explain his weakness, and Joseph knew he wasn’t diabetic, anyway. Then there was Lambert-Eaton syndrome, a type of weakness that can signal lung cancer. Joseph’s smoking background was worrisome, but Lambert-Eaton is rare.

There was a likelier possibility.

Writing my guess down on a receipt, I tucked it into Joseph’s shirt pocket, then urged him to visit the ER, where he’d get a spinal tap and possibly a brain scan. (It didn’t seem wise to rule out a brain problem based on a barroom exam). If this was what I thought it was, it could get worse fast. It could even stop him from breathing.

A Near Miss

Joseph’s wife, Holly, had returned from out of town that day. From the bedroom, she heard him come home. “I hear the door swing open, slam against the wall, and then I hear this thud,” Holly remembers. “It sounded like a monster was coming in.” Joseph’s clumsy tread was rattling the house.

Joseph told Holly he had met a doctor at the bar, and he showed her the piece of paper I had tucked into his pocket. Holly wanted him to go to the ER right away; Joseph thought he could wait until Monday. Holly won.

Within hours, Joseph was admitted to the hospital, the ER nurse having made a “doorway diagnosis” long before any test results were in. A few hours later, my barroom diagnosis was confirmed by a spinal tap, which revealed abnormally high protein levels — a finding that’s believed to be from inflamed nerve roots. Joseph had Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is thought to be an autoimmune disease in which the body attacks its own peripheral nervous system, starting with the feet and hands. It often starts with limb weakness and a loss of reflexes. GBS can also cause other nerve problems, like sensory disturbances and difficulty swallowing. (I later learned that Joseph had trouble swallowing his pub meal that day, but he didn’t want to bring attention to his condition.)

Usually, GBS develops soon after an infection, most notoriously with a diarrheal bacterium called Campylobacter. Some of that bug’s characteristics resemble lipids in the nervous system. That resemblance may cause the immune system to attack, resulting in the destruction of myelin, the fatty insulation that lines the nerves. It’s unclear what aggravated Joseph’s immune system. Although he had recently been under the weather, he hadn’t had any bowel problems, the hallmark of Campylobacter infection.

Whatever set off his illness, things didn’t go easily for Joseph after his diagnosis. His legs and arms grew weaker and weaker until they were almost paralyzed. Then his diaphragm began to give way, robbing him of his ability to laugh: When a nurse joked with him, he managed only a groanlike “huhhhhh.”

“I felt like I was down a drain looking up through the drain hole,” he said later. Although GBS has a good prognosis, its effects on the diaphragm make it life-threatening; the patient may need a ventilator to support his breathing until the illness subsides.

Joseph escaped that fate. His doctors ordered intravenous immunoglobulin, a solution of antibodies that neutralizes the body’s attack. After that his symptoms slowly receded, and 17 days after admission, he went home in a wheelchair. Four weeks later, he swapped it for a cane, and by mid-September, two months after his illness struck, he was back at work, installing his lions in time for the races. Several months later, he had only some lingering numbness in his feet. That’s typical: Most GBS patients get better, but recovering fully can take a year or longer.

Recently, Joseph and Holly met my husband and me for lunch. His paralysis, he told us, had been an eye-opening taste of hopelessness. Unable to lift his arms, he couldn’t imagine ever carving again, and the debility made him feel like an old man. “It’s almost more bizarre that you recover,” he said. “I’m having to get used to being young again.”